Individual at Erlestoke House

Investigation into the circumstances surrounding the
death of a man
at HMP Erlestoke in April 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2009
This is the report of an investigation into the circumstances of the death of a man in
April 2009, while a prisoner at HMP Erlestoke. He was 51 years old at the time of
his death from a heart attack.
The man had suffered from heart problems, diabetes, depression, chronic
obstructive pulmonary disease (COPD) and epilepsy for a number of years. Despite
these difficulties, his death was sudden and unexpected. I would like to offer my
sincere condolences to his family as well as to staff and prisoners who knew him well
and were touched by his death.
My colleague conducted the investigation. An independent review into the man’s
medical care was undertaken by a clinical reviewer on behalf of the local Primary
Care Trust. I am grateful to him for his valuable contribution. I would also like to
thank the Governor of Erlestoke and his staff for their cooperation and assistance
with the investigation. In particular, I am indebted to the Head of Healthcare and her
staff who provided a very high standard of liaison and the man’s personal officer,
who gave helpful information about his time on Wessex Unit.
One of the Ombudsman’s Family Liaison Officers contacted the man’s daughter.
She spoke very highly of the care her father received and was grateful to staff for
their support following his death.
I make one recommendation relating to record keeping which the prison service has
accepted.
My recommendation aside, I agree with the clinical reviewer’s conclusion that the
medical care the man received at Erlestoke was appropriate and possibly exceeded
that which he would have experienced in the community.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Deputy Prisons and Probation Ombudsman August 2009
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CONTENTS
Summary
The investigation process
HMP Erlestoke
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
In May 2006, the man was sentenced to five years imprisonment for a violent
offence. He began his sentence at HMP Winchester. He entered prison with a
number of long term medical conditions, the most serious being heart problems.
According to his medical history, he had his first heart attack before he was 40 years
old. As well as ischaemic heart disease, he also had a history of chronic obstructive
pulmonary disease (COPD), epilepsy and diabetes. He was a heavy smoker and,
despite encouragement from healthcare professionals and his own efforts, he was
unable to give up smoking.
The man completed his induction on the first day. At that interview, he said he did
not have problems with asthma or diabetes, but had suffered with epilepsy all his life.
He said he was allergic to the GTN spray given for angina relief. (This was a
significant factor in how the prison service managed his angina and explained why
he was frequently transferred to hospital to manage his angina safely and
successfully.) He also told healthcare staff he had suffered a nervous breakdown in
2004. His medical records showed that he was overweight, had high blood
pressure, heart disease and smoked despite advice.
Throughout his sentence, the man was described as polite and conforming to the
prison regime. He was trusted by staff and worked as an orderly for the chapel and
as a wing cleaner when he was able. He was transferred to Erlestoke on 14 August
2007 to an offending behaviour course. However, he was unable to complete the
courses due to his ill health.
Angina attacks and consequent admissions to hospital were a constant feature of the
man’s life. He was allocated to ground floor cells because of his heart problems. He
also underwent a medical procedure to put a stent into his artery. His diabetes was
managed through attendance at the diabetic clinic where he was encouraged to give
up smoking and plans were made to improve his diet and resume taking exercise.
At Erlestoke, he had regular appointments with healthcare staff for his heart
problems and COPD.
In November 2007, a prison doctor discussed with the man whether a prison with a
24 hour inpatient facility would be more appropriate for his needs. They agreed that
it would be, but he was a category C prisoner and was reluctant to return to a
category B prison. (The clinical reviewer takes the view that given the suddenness
of the man’s collapse, it was very unlikely that a move to a 24 hour healthcare facility
would have affected the eventual outcome.)
On 1 February 2008, the man was noted to be depressed and distressed. An urgent
referral was made for a mental health review, but staff decided not to initiate
monitoring under the Assessment, Care in Custody and Teamwork (ACCT)
procedures. (ACCT is a process designed to support and monitor prisoners at risk of
self-harm.)
In September, the man applied for category D status to enable him transfer to an
open prison closer to his home and receive visits from his family. They had been
unable to visit owing to the distance between the prison and their home.
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On 1 April 2009 at around 8.00am, two officers were unlocking cells and another
officer was handing out milk for breakfast in the servery. A prisoner alerted the
officer who was handing out milk that the man had collapsed in his cell. The officer
called for assistance and a prisoner went to the wing office to alert a second officer.
Neither the second officer nor a SO were able to find the man’s pulse. Therefore the
SO instructed the second officer to call an ambulance and, together with two nurses,
he carried out cardio pulmonary resuscitation (CPR) until a paramedic arrived at
8.45am. At 9.05am, the man’s death was confirmed by a doctor.
The man’s family were told of his death by the prison Family Liaison Officer and the
Governor.
I conclude that the care the man received was timely and appropriate and his death
was unavoidable. I make one recommendation in relation to record keeping which
the prison service has accepted.
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THE INVESTIGATION PROCESS
1. The Ombudsman was notified of the man’s death on 1 April 2009. Terms of
Reference and notices were issued to staff and prisoners at HMP Erlestoke,
telling them that an investigation would be taking place, and inviting those who
wished to see the investigator to make themselves known. The investigator
requested copies of the core record, medical record, and other records relevant
to his time in custody and to his death.
2. The investigator also contacted the Coroner to inform him of the nature and
scope of the investigation and to request a copy of the post mortem report. The
report was not available during the investigation or before publication of this
report. However, the Coroner’s officer told the investigator that the man died of
ischaemic heart disease. The Coroner has requested a copy of this report upon
completion and I am happy to comply.
3. The investigator visited Erlestoke on 12 June 2009. She met the Governor and
his staff. She visited Wessex Unit and spoke with the man’s personal officer.
She also spoke with the Head of Healthcare.
4. A clinical review of the man’s medical care was commissioned from the local
Primary Care Trust. It was undertaken by a clinical reviewer who considered the
clinical care the man received at Erlestoke and spoke by telephone on a number
of occasions with the investigator. His clinical review appears as an annex to
this report.
5. The man named his daughter as his next of kin. One of the Ombudsman’s
Family Liaison Officers spoke with the man’s daughter. She told the investigator
that her father had a “fantastic rapport” with everyone in healthcare. The family
have asked for a detailed account of the morning when he died and I have tried
to provide it for them.
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HMP ERLESTOKE
6. HMP Erlestoke is set on the former grounds of Erlestoke Manor House in rural
Wiltshire. It is a category C adult male training prison and the only prison in the
county. It has an operational capacity of 470 prisoners located across nine
residential units. The average age of prisoner population was younger than the
man.
7. He lived in Wessex Unit which holds 68 prisoners of both standard and
enhanced status. (There are three levels of status given to prisoners. Enhanced
awards additional privileges to prisoners who comply with their sentence plan
and show respectful behaviour. Standard status is applied to prisoners who show
respectful behaviour but need to work harder on their sentence plan or other
aspects of their behaviour. Basic status reduces the number of privileges to a
very low level and is given to those whose show poor behaviour and compliance
to the prison regime.) A member of the Independent Monitoring Board (IMB)
described the unit as “adequate but jaded”. He said that necessary maintenance
had been left in the past and now been completed by the new governor. HM
Chief Inspector of Prisons had criticised some aspects of the accommodation in
the past. Wren Unit had been assessed as being in particularly poor condition
and closure of the unit was advised. This remains the case.
8. Erlestoke does not have an inpatient facility. Doctors from a local surgery
provided medical cover during the day from 8.00am to 6.30pm. Evening and
weekend cover was provided by the out of hours service as provided to the
community. Healthcare provision and accommodation had improved since the
last inspection. The Head of Healthcare described the healthcare department as
nearly fully staffed. Interviews with prospective nursing staff were to be held on
the afternoon the investigator spoke with her, which would bring the unit to a full
nursing complement.
9. In her report of an announced inspection from 28 April to 2 May 2008, HM Chief
Inspector of Prisons said that the prison could be commended overall for
purposeful activities and resettlement. However, at the time of her inspection,
she identified a serious drug problem and a failure to provide basic equipment
such as clean bedding.
10. During the investigation the investigator spoke with the member of the IMB who
said that matters had greatly improved which had coincided with the change of
governor. He advised that a proactive stance had been taken in running the
prison and the number of complaints the IMB received had reduced considerably
from around six per week to six per month. As an example, he described the
general atmosphere of the prison as “far more settled” with clear guidance given
to prisoners on how to complain unlike the previous complicated process.
11. This is the third death investigated at Erlestoke, since 2004 when the
Ombudsman was given responsibility for investigating deaths in custody and
were due to natural causes. Recommendations have been made in the past; but
none are relevant to this investigation.
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KEY FINDINGS
12. The man was sentenced at Crown Court on 4 May 2006 to five years
imprisonment for a violent offence. He was received into HMP Winchester to
begin his sentence. This was not his first time in prison.
13. An entry in the wing history sheet records that he completed his induction into
the prison on the same day. The personal summary sheet completed by an
officer said that he had named his daughter as his next of kin. He described
himself as disabled, a smoker and his religion as Jewish.
14. On the same day, the first reception health screen document was completed by
healthcare staff. It lacked important information in a number of areas including
the name and status of the member of the healthcare individual completing it.
Neither did it say whether the man was suitable for normal location and in any
cell or whether he should be referred to a doctor for a further assessment. The
document showed the basic information he gave to the healthcare officer
regarding his doctor’s contact details and his health. He said he suffered from a
heart condition and had been released from “hospital, Cosham today”,
suggesting that he had been released from hospital that day, before attending
court for sentencing. He said he did not have problems with asthma or diabetes,
but had suffered with epilepsy all his life. He maintained he was allergic to the
GTN spray for angina.
15. The man revealed that he had suffered a nervous breakdown in 2004 and had
received treatment from a psychiatrist. He said that he had not been admitted to
a psychiatric hospital but had received help from a psychiatric nurse or
careworker while he was in the community.
16. The secondary health assessment carried out on 29 November 2006 recorded
that he was overweight, had high blood pressure, heart disease and smoked.
The form did not show whether or not he wished help to stop smoking.
Throughout his sentence and numerous attendances and admissions to hospital,
He was advised to stop smoking by hospital and prison healthcare staff.
However, despite attempts and encouragement from staff, he was unable to do
so.
17. October entries in the man’s wing history sheet say that he was working well as a
cleaner and was an enhanced status prisoner.
18. An entry in his wing history sheet on 5 November described him as a quiet man
with “some medical problems”. Another entry two days later said that he was to
be located on the ground floor of the wing because of his heart problems. He
obeyed the wing rules and was often seen by staff out of his cell taking gentle
exercise.
19. The corresponding entries in the man’s medical record for around this time focus
on officers’ concerns about the pain in his chest and difficulty breathing. In early
December, his medical record notes that he returned from an emergency visit to
hospital, after complaining of chest pain. A plan is set out in the record but the
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abbreviations used do not make the details clear. It was noted that a discharge
summary had not been received from the hospital.
20. The man went to the diabetic clinic on 17 November 2006. His condition was
monitored through blood tests and smoking cessation and diet were discussed,
with a plan that exercise was to be restarted.
21. As an enhanced status prisoner, he became a chapel orderly in January 2007
and continued to do well in prison. While he was complying with prison rules and
coping with his sentence on the wing, his medical record gives the impression of
an individual who visited healthcare regularly with cardiac and other unrelated
problems. His cardiac problems continued and an ambulance was called again
in March 2007 after a member of healthcare staff was called to see him in B
wing. The healthcare officer noted that he was depressed but had not been
prescribed medication for depression at that time.
22. The man underwent a medical procedure on 20 March to put a stent into his
artery. (A stent is a tube placed inside a vein or artery to keep it open.) On his
return, he asked to be placed in a single cell on medical grounds. In late March,
he complained of migraine headaches and was asked by medical staff to record
their frequency so his condition could be monitored and a referral made to the
doctor if necessary. There do not appear to be any further references to
migraines in his medical record.
23. A memorandum dated 29 March 2007 from locum medical officer to the senior
officer on B wing confirmed that the man no longer needed to be restricted to
ground floor accommodation and was suitable for B wing.
24. By April and following his operation to have a stent, he was described in his
medical record as “No more angina. Feeling very well in himself. Very keen to
leave this prison and go to Channings Wood.”
25. An entry in the wing sheet dated 19 April said that the man had been “accepted
anytime” on transfer from Winchester to HMP Channings Wood. He arrived at
Channings Wood on 2 May and went through the first night and induction
process. Early on, his heart problems were acknowledged and he was allowed
to have a soft chair in his cell on A wing. The wing sheet records that, on 30
May, a transfer application for HMP Erlestoke was completed. (The transfer was
specifically for him to undertake an offending behaviour programme to reduce his
risk of re-offending.)
26. While awaiting transfer, the man was employed as an induction orderly on 12
June. However, six days later on 18 June, his wing record shows that he was
taken to hospital with a suspected heart attack. He returned to the prison the
following day with a discharge summary advising on the medication he should
take. The medical record highlighted that he had refused an angiogram and did
not wish to go to prison healthcare on his return. (An angiogram is performed by
injecting a substance that clearly shows the cardiac vessels.)
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27. It appears that a few days later, the man changed his mind about the angiogram.
Healthcare staff thought the appointment should be made as soon as possible
and telephoned ahead to ascertain waiting times. They were informed that the
urgency was decided by a consultant but the wait was “never longer than 11
weeks” and so they pressed for an urgent appointment. An appointment was
received for 10 July but there is no evidence in the medical record to show
whether he attended.
28. Due to the frequency of his admissions to hospital, a letter dated 20 June 2007
was drafted by the Clinical Lead of the Devon Prison Cluster and addressed to
the accident and emergency department of Torbay Hospital. The letter had been
written to hold at the gate of Channings Wood in the event of out of hours
emergency treatment being required. It set out his condition, existing medication
and next of kin details.
29. The man transferred to HMP Erlestoke on 14 August 2007 and was located on
Wren unit. He underwent a medical reception health screen which included a
Prison Service disability assessment. At that interview, he told staff he had
suffered five heart attacks and had chronic obstructive pulmonary disease
(COPD). He confirmed that he was epileptic but had not had a fit for around
eight years and was allergic to the GTN spray for angina. He said he smoked
and preferred a single cell as his sleep was disturbed.
30. He had transferred to Erlestoke specifically to undertake an offending behaviour
programme. He completed the induction programme for the course on 28
September. However, his deteriorating health impaired his ability to successfully
complete the programme and he was taken off the course. The course manager
spoke to healthcare about her concerns in mid September and followed this up
with an email. She questioned whether he should be returned to Channings
Wood as he had failed to complete the course. There is no evidence of a formal
response to the suggestion of a return to Channings Wood, but wing sheets
record that he felt the programme was too stressful for him. On his behalf she
asked staff whether he would be eligible for a disability wage. The response was
that a decision would be made once the outcome of his angiogram was known.
In the meantime, wing staff had kept him active by allowing him to assist with
wing cleaning.
31. Between 11 September and 19 December, the man had numerous appointments
with healthcare staff for his heart and COPD condition. Staff monitored and
treated him appropriately. However, the investigator was concerned to note that
an escort required to take him for a coronary angiogram on 20 November was
cancelled as another appointment took priority. This decision had been taken
despite the Medical Appointment (Escort Slip) stating that the appointment was a
“No. 1 App URGENT (must not be cancelled). His appointment was rearranged
for two weeks later on 4 December.
36. On 6 November, the prison doctor discussed with the man whether a 24 hour
inpatient facility would be more appropriate for his needs. The man agreed that
this would be more suitable, but was reluctant to be downgraded to a category B
solely because of his health. He said that he would like to return to Winchester if
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possible. The man also anxious about the length of time it took for an ambulance
to travel to the prison due to its rural location. A second prison doctor wrote twice
to the governor asking for him to be transferred to a prison with a 24 hour in
patient facility. (The clinical reviewer has considered this matter in his review
which is annexed to this report.)
37. When visited by nursing staff on 1 February, the man presented as being
distressed and very low in mood. Healthcare staff made an urgent referral to the
mental health team and he was seen two days later by a mental health worker.
38. On 21 September, a prison officer, and also the man’s personal officer, made an
entry in the wing history sheet. He said that the man had just completed the
Victim Awareness course and had told him that he had 11 and a half months of
his sentence remaining. During their conversation, the man said he was trying to
attain category D status so he could transfer to a prison closer to his home and
receive visits from his family. At the time, they were unable to visit as it was too
far for them to travel.
39. The officer told the investigator that he had been the man’s personal officer for
the seven months before his death and knew him well. He said that the man
would have told staff if he was ill. He recalled that there was always someone
with him. He had a system in place whereby he could bang on the wall of his cell
to his friend in the cell next door if he needed help. He said he thought that the
man was honest with him if he was feeling down, but put a brave public face on.
The investigator was impressed with the officer’s commitment to his role as a
personal officer when he told her that he had volunteered to undertake the man’s
hospital bedwatch on five or six occasions because he knew him well. He
recalled that the man had discharged himself from hospital on the last occasion
he carried out a bedwatch. He thought this was because hospital staff could not
find a vein and had to inject him in his toe. This incident gave the officer the
impression that there was an element of the man being tired of his ill health and
wanting to give up.
40. During 2008, the man continued to experience bouts of chest pain resulting in
admissions to hospital. The clinical reviewer has identified that, specifically, in
February, July and August 2008, the man had several overnight admissions to
hospital because of chest pain. Hospital discharge summaries say that he did
not have heart attacks, but repeated bouts of angina combined with muscular
chest pain. Troponin tests at the hospital were negative. (Troponins are a group
of proteins found in muscle. Heart specific troponins may be detected in the
blood between four hours and 14 days after heart muscle damage and is a highly
specific and sensitive test for heart attack.) His low mood continued as his
health deteriorated. In spite of chest pain on 12 September, he refused to go to
hospital. Healthcare staff allowed him to keep oxygen in his cell and informed
wing staff. He continued to attend the diabetic clinic and received counselling for
depression.
41. The man was encouraged to lose weight and stop smoking. He attended a
smoking cessation course on 30 September. He was assisted by nicotine
patches and advised to stop smoking within four weeks. However, he found it
11
too difficult to give up smoking completely. He was also encouraged to take
gentle exercise in the gym, but was reluctant to do so.
42. On 3 March 2009, the man went to healthcare because of a chest infection, for
which he was given antibiotics. He was also still awaiting the decision on his
application for category D status.
Events in April
43. An officer was on duty in Wessex unit at 7.45am. He said that he and another
officer unlocked the cells at around 8.00am and the second officer handed out
milk for breakfast at the servery. He said he unlocked the first floor landing cells
and the other officer unlocked the ground floor cells where the man was located.
It appears that when his cell was unlocked, the man got up and prepared himself
for work as usual. The prison family liaison log reported that he was wearing his
prison work clothes when he was found collapsed in his cell.
44. In his incident statement, a third officer confirmed that he was distributing milk to
prisoners at the servery on the wing. He said that at around 8.20am, a prisoner
told him that the man was lying on the floor of his cell. He said he looked
through the observation panel in the cell door. He saw that the man was already
in the recovery position on his right side on the floor facing the bed. The officer
called his name as he went into the cell. He then immediately called for medical
assistance using his radio. He asked the prisoner to alert staff to the incident
and he tried to keep other prisoners away and keep things calm. He said he
remembered a Senior Officer (SO) arriving quickly at the cell and so he left.
45. After unlocking the cells, the first officer said that he and the second officer
returned to the office where they were kept very busy dealing with queries from
prisoners. The third officer remained at the servery. At around 8.20am, a
prisoner came to the office and told the second officer that another officer (the
third officer) needed him urgently. He said that at around 8.24am while the
second officer was gone, he took a telephone call from a nurse asking him why
she was needed on the unit. (The Head of Healthcare explained to the
investigator that the nurse would have telephoned to ask what equipment she
should bring.) The second officer replied that he did not know as both the other
officers were out of the office. It appears that the nature of the emergency was
not explained to the communication unit and so the nurse did not know what was
required. The first officer recalls that the third officer returned to the office “in a
rush” and rang the communications department to instruct them to call an
ambulance.
46. The second officer recalled that he was in the wing office at around 8.20am when
a prisoner came into the office and told him that the third officer needed him
urgently at cell 45. (Cell 45 was the man’s cell.) He said he “rushed down to cell
45” and saw the man lying on his right side on the floor. In his statement, he said
he tried to feel for a pulse but after 30 seconds, could not feel anything. The
third officer had told him that he had already informed healthcare of the
emergency by radio. The table was removed from the cell to give more space.
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The second officer was told over the radio net that the SO, the Wessex unit duty
manager, was on his way.
47. When the SO arrived, the second officer told him he could not find a pulse but
that he was not trained in first aid. The SO also checked the man but could find
no pulse or sign that he was breathing. The second officer said that the SO told
him to get the incident pack, telephone for an ambulance and to get the duty
principal officer to Wessex unit as soon as possible. Having given the second
officer instructions, the SO said he immediately placed the man on his back and
began chest compressions. At that point, two nurses arrived with oxygen and
they began cardio pulmonary resuscitation (CPR) until a paramedic arrived at
8.45am. The SO then left the cell.
48. When the second officer returned to the office at around 8.25am, he immediately
telephoned the communications office to ask for an ambulance and for the duty
principal officer to attend Wessex unit. In his statement, he said he went back to
the man’s cell with the first aid kit. He was told that this was not what was asked
for. He told the healthcare staff that he could not find the incident pack but they
did not reply.
49. The second officer remained outside the cell keeping prisoners away. When the
Principal Officer (PO) arrived at around 8.40am, he asked the officer to lock
prisoners in their cells.
50. In his statement, the PO said he responded to a call asking him to go to the unit.
When he arrived, he was directed to cell 45 where he saw two nurses and the
SO giving the man CPR. He instructed that all prisoners were to be locked in
their cells to enable the emergency response teams to move onto the unit
unhindered. The PO said the paramedics arrived and, recognising that the SO
had performed CPR for around 30 minutes, he accompanied the SO to a quiet
area of the unit where he was able to wash and have a drink. He arranged for a
member of the Care Team to speak with him before he went off duty.
51. The Incident log records that the air ambulance was given permission to land on
the prison sports field. It landed at 8.54am. The ambulance arrived at 8.46am
and at 9.03am the air ambulance was no longer required. The incident log entry
says that at 9.05am, the man’s death was confirmed by a doctor.
52. The PO said that while prisoners in Wessex unit remained locked in, the staff
were relieved by other colleagues. They went to a quiet area to prepare
statements and speak to the Care team.
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Events after the man’s death
53. The Family Liaison Log of Contact records that the Family Liaison Officer arrived
on duty at 10.00am on the day the man died. She found his next of kin details
and spoke with the police. Both she and the Governor travelled to the home of
the man’s daughter at 2.30pm where they gave her the news. The Family
Liaison Officer log records that she left her contact details with the daughter.
54. The following day, the Family Liaison Officer spoke with the man’s daughter on
the telephone. She discussed a memorial service and his cremation. His
daughter wished to have the opportunity to come to the prison to see her father’s
cell and attend the memorial service. The investigator spoke with the Governor
who said that staff and around 60 prisoners went to the service. The man’s
daughter and son-in-law attended and were given gifts and cards.
55. The family said they were happy with the care the man had received and did not
raise any issues at that stage. The prison chaplain conducted the memorial
service as well as his funeral in the community. Prison staff attended and his
property was handed to the family on the day of his funeral as previously
arranged.
56. One of the Ombudsman’s Family Liaison Officers spoke with the man’s daughter.
She described her father’s death as a “tremendous shock” as he was due for
release shortly and the family were looking forward to having him home to live
with them again. She said that her father had a “fantastic rapport” with
healthcare staff at Erlestoke. She said he never complained about his treatment
which was in stark contrast to his experience at Winchester where he had been
critical of staff.
57. The man’s daughter described the prison family liaison as “absolutely fantastic”.
She mentioned that the family had been invited to attend the prison memorial
service on 8 April and it had been very important to them to attend.
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ISSUES
Clinical care
58. The clinical review was undertaken by a clinical reviewer of the local Primary
Care Trust. He reviewed all the necessary records and discussed aspects of the
man’s medical care with the investigator. The clinical review acknowledges that
the man was a patient with a number of longstanding medical conditions. The
clinical reviewer identified ischaemic heart disease as the most serious of these.
He had a history of heart attacks, the first when he was under 40 years old. He
also had COPD, which the clinical reviewer advised was the result of lung
damage due to heavy smoking, a habit which the man had found impossible to
give up. He was also known to be epileptic and diabetic although these
conditions were controlled with medication. The clinical reviewer concluded that:
“Sadly, his early death is not unusual in such a patient, and it appears that his
medical care was at least as good as would have been available to him if the
man had been at liberty during the period of his illness. There are no
recommendations to make which could be expected to avert a similar
situation in future.”
Transfer to a prison with 24 hour healthcare facility
59. The investigator became aware of the frequency of the man’s admissions to
hospital, the potential impact of this on the regime and the rural location of the
prison. The Head of Healthcare explained that he was frequently admitted
because he was allergic to the GTN spray which is used to ease angina. She
said he had to be sent to hospital for his condition to be managed effectively.
60. The issue of whether the man should have been transferred to a prison with a 24
hour healthcare facility, such as Winchester, was raised in correspondence by a
medical officer at Erlestoke. However the investigator could find no record of a
response.
61. The clinical reviewer considered whether the man’s health needs would have
been best met in a prison with 24 hour healthcare facilities and concluded that
they would not. He was of the view that the man’s transfer request had no
relevance to the circumstances of his death as he died suddenly without an
opportunity to call for help. Transfer to a 24 hour healthcare facility was
discussed with the man who said he was happy to remain at Erlestoke despite
his concern about the ambulance response times. On this occasion the air
ambulance arrived within ten minutes of the prison making the emergency call
regarding his collapse, which seems reasonable in the circumstances.
62. The man was not transferred to a prison with a 24 hour healthcare facility and I
am satisfied that it did not affect the outcome on this occasion. However, this
may not always be the case and it may be considered an appropriate option in
the future where the progress of a medical condition is slow and it is in the
patient’s best interest.
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Evening staffing arrangements
63. The investigator also learned that the man became unwell mainly in the evenings
when staffing levels on the wings were low and healthcare cover was provided by
an out of hours service. The investigator spoke with wing staff to explore
whether they had any concerns about dealing with his frequent bouts of angina
and his subsequent collapse. One member of staff said that they were not all
first aid trained and only senior officers were trained in first aid and CPR.
64. The investigator raised this issue with the Governor. His response was that a
rota system is in operation which ensures that there is always a member of staff
on duty who has had appropriate training. In this case, the third officer was first
to arrive at the man’s cell and was not first aid trained. The SO, who arrived
shortly after, started CPR and continued until healthcare staff arrived minutes
later.
65. In this instance it was not crucial that the first member of staff on scene was not
trained, however in a future incident it might prove to be so. I make no
recommendation here as it is acknowledged the current system did not affect the
outcome. However, feedback from staff suggests that some would welcome the
opportunity of having first aid training to increase their confidence in dealing with
medical emergencies if they are first to the incident.
66. The investigator spoke with the Governor regarding the man’s collapse. He said
he was very impressed by the huge efforts made by staff to save the man’s life.
The investigator has seen a copy of each Governor’s Commendation for Prisoner
Care awarded to the two nurses and the SO cited “In recognition of your actions
of the 1 April 2009 whereby you made a valiant and sustained attempt to save
the life of the man”.
Record keeping
67. The records held at Erlestoke are electronic but the quality of the information held
is dependent upon the individual recording it. While entries are timed and dated,
the status of the individual making the entry is not clear. The prefix of ‘Dr’ is
obvious but it is not immediately clear whether all other staff named on the
medical record are medical professionals, administrative staff or visiting
clinicians.
67. The investigator found evidence that a hospital appointment for the man to have
a coronary angiogram in 2007 was cancelled as another appointment took higher
priority. The healthcare administrator told the investigator that one hospital
escort in the morning and one in the afternoon were permitted. She said that if
an appointment had to be cancelled, she did so following advice from a doctor or
a member of the nursing staff. She said the incidence of cancellation in these
circumstances was rare.
68. The investigator discussed this issue with the clinical reviewer. He is of the view
that in this case it was not critical to the man’s care. However, both he and the
investigator raised the concern that there is no evidence of the appointment in
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the medical record. Neither is there any entry which explains how the decision
was made or the circumstances supporting the cancellation.
The head of healthcare should ensure that staff record their professional
status when making entries on the medical record and that a record is
made of all hospital and other external appointments as well as the reasons
for any cancellation.
Emergency codes
68. The investigator noted that nursing staff had to ring the wing office in order to find
out the type of emergency she had been called to and the equipment she was
expected to bring. The Head of Healthcare confirmed that an emergency code
system to alert healthcare to the type of emergency was not in place. She also
confirmed that a Governor’s Notice dated 10 June 2009 had since been issued
telling staff that a code system had been introduced. Staff who are first on scene
to a medical emergency are to give a code sign of Code Red for cardiac,
respiratory and blood evident emergencies and Code Blue for all other incidents
requiring medical assistance deemed urgent but not a medical emergency. I am
pleased that action has been taken and, in the circumstances, I do not make a
recommendation.
Assessment, Care in Custody and Teamwork monitoring
69. The investigator observed that the concern on 1 February was such that perhaps
opening an ACCT document should have been considered. She discussed this
with the governor who agreed that, with hindsight, this might have been the
appropriate course of action. The investigator also noted an entry in the clinical
record said that the man felt comfortable approaching staff when he was
experiencing difficulties and on balance staff monitored him and he was rarely left
on his own by his friends in neighbouring cells.
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CONCLUSION
71. The man arrived in prison with a number of medical conditions. The most serious
was ischaemic heart disease. I believe that he was treated regularly and
appropriately. However, I endorse the clinical reviewer’s comments regarding
the standard of care. The investigation found that, in all the circumstances and
despite the best efforts of staff, his untimely death was unexpected and
unavoidable.
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RECOMMENDATIONS
The head of healthcare should ensure that staff record their professional status when
making entries on the medical record and that a record is made of all hospital and
other external appointments as well as the reasons for any cancellation.
Accepted.
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